57 YEAR FEMALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Radhesh Mahankali, Roll no 131

A 57 year old female patient presented to the OPD with chief complaints of decreased urine output since 3 days  and shortness of breath since one day

HISTORY OF PRESENT ILLNESS

57 year old female patient resident of sirikonda housewife by occupation. She was apparently asymptomatic 3 years back then she had low back pain which was radiating to groin diagnosed as renal caliculi managed conservatively f/b diagnosed with CKD managed conservatively.

Decreased urine output since 3 days 

Sob grade II-III since yesterday night

Cough with sputum yellowish in colour intermittent f/b blood tinged sputum 

And fever not associated with chills and rigors 

PAST HISTORY:

No similar complaints in the past

 MEDICAL HISTORY:

No history of diabetes, hypertension, tuberculosis, epilepsy, asthma.

FAMILY HISTORY:

No relevant family history

PERSONAL HISTORY:

-Mixed diet

-Reduced appetite

-Adequate sleep

-Regular bowel movements

-micturition: Pt has decreased urine output.

GENERAL PHYSICAL EXAMINATION:

Pallor - Present

Icterus - Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal oedema - Present (pitting type)

Vitals:

Temperature- afebrile

Pulse rate- 89 beats per minute

Respiratory rate- 22 breaths per minute

B.P- 110/70 mm hg

SpO2- 90% at room air

SYSTEMIC EXAMINATION

Cardiovascular system- s1 and S2 are heard                                             no murmurs are heard

Respiratory system:

Dyspnoea- present

Breath sounds- decreased breath sounds in right IIA and SSA

Vesicular breath sounds are normal

Wheezing- present

BAE- positive

Central nervous system- Patient was conscious coherent and cooperative.

Speech was normal.

No slurred speech

No meningeal irritation signs 

-No abnormality detected.

REFLEXES

Right and left biceps triceps supinator ankle and knee show grade 2 Reflex

GAIT - Normal

                      INVESTIGATIONS

      X-RAY:

                 LAB INVESTIGATIONS:

                          ECG:

                        PLEURAL TAP:

PROVISIONAL DIAGNOSIS:

CKD with right sided pleural effusion

            TREATMENT:

1.Pleural tap

2. Head end elevation up to 30°

3. O2 supplementation if SpO2 is less than                90%.

4. Fluid restriction < 1 litre per day

5. Salt restriction < 2.4 G per day

6.Inj. Augmentin 500 mg/ IV/ OD

6. Tab. Azithromycin 500 mg/ OD

7. Inj. Lasix 40 mg IV/ BD

8. Tab

9. Tab shelcal 500 mg audi

10. Tab orofer-xT /OD

11. Inj. Erythropoietin 4000 IU s/c weekly   once

12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis

13.Syrup. Ascoryl 10ml /TD

14. Monitor vitals hourly

15. Strict I/O Charting